Donnelly College Counseling Center INTAKE FORM

Donnelly College Counseling CenterINTAKE FORMDate ________________________Name:___________________________________________________________ Gender: Male FemaleLast First MiStudent Academic Major GPA Hours enrolledPlace of employmentWork hours per weekFaculty/Staff Position ExtensionDonnelly ID #__________Date of Birth_________ Age_______ Ethnicity/Primary Language__________________Address________________________________________________________________________________________Best Phone # to Reach You_________________ If we need to contact you, may we leave a message? Yes NoEmail address___________________________________________________________________________________In case of emergency (such as hospitalization, ER visit, suicide risk, or if the counselor is unable to reach you for anextended period), is there someone you give the Counseling Center permission to contact?Name___________________________ Relationship _____________ Phone 1__________ Phone 2____________Relationship Status: Single Significant Other MarriedSeparated Divorced WidowedLiving Situation:Specify________________________________________________________________(For example: parent(s), spouse, friend, roommate, self, etc.)How did you learn about the Counseling Center? _____________________________________________________Who referred you? Self Faculty Academic AdvisorFriend Parent Student ServicesOther _____________________________________________________________OPTIONAL: I give my permission to the Donnelly College Counseling Center to notify the following person who referred me.This notification is solely for the purpose of confirming my contact with the Donnelly College Counseling Center:Name of Referral Person______________________________________________________ Phone _______________________Your signature_______________________________________________________________ Date _______________________Are you presently receiving or seeking counseling from some person or agency other than this Center?Yes No With whom? __________________________________________________Have you received counseling services in the past?Yes No With whom? ___________________ When _______ How Long _______1

Donnelly College Counseling CenterList any current or previous medication or physical conditionsINTAKE FORMDo you have a disability? Yes NoIF YES, please describe_____________________________________________________________________Do you have a personal primary health care provider? Yes NoIF YES, please list name & address _______________________________________________________________________________________________________________________Date of last physical exam _________________________________________________________________What are the subjects of your concern? (check all that apply)My emotional well-beingMy academic performanceMy stress levelWhat is the main concern you are bringing to counseling?My relationship with othersMy career/vocational plansMy physical health(please be specific)How much distress has this caused you in the past week, including today?___________________________________________________________________________________1 2 3 4 5None A little bit Moderate Quite a bit SevereHow much is this concern interfering with your usual routine?___________________________________________________________________________________1 2 3 4 5None A little bit Moderate Quite a bit SevereHow much is this concern interfering with your ability to perform academically?___________________________________________________________________________________1 2 3 4 5None A little bit Moderate Quite a bit SevereHow much is this concern affecting you socially?___________________________________________________________________________________1 2 3 4 5None A little bit Moderate Quite a bit SevereWhat do you want to be different as a result of coming to counseling?2